Motile cilia and airway disease

A finely regulated system of airway epithelial development governs the differentiation of motile ciliated cells of the human respiratory tract, conferring the body's mucociliary clearance defence system. Human cilia dysfunction can arise through genetic mutations and this is a cause of debilitating disease morbidities that confer a greatly reduced quality of life. The inherited human motile ciliopathy disorder, primary ciliary dyskinesia (PCD), can arise from mutations in genes affecting various aspects of motile cilia structure and function through deficient production, transport and assembly of cilia motility components or through defective multiciliogenesis. Our understanding about the development of the respiratory epithelium, motile cilia biology and the implications for human pathology has expanded greatly over the past 20 years since isolation of the first PCD gene, rising to now nearly 50 genes. Systems level insights about cilia motility in health and disease have been made possible through intensive molecular and omics (genomics, transcriptomics, proteomics) research, applied in ciliate organisms and in animal and human disease modelling. Here, we review ciliated airway development and the genetic stratification that underlies PCD, for which the underlying genotype can increasingly be connected to biological mechanism and disease prognostics. Progress in this field can facilitate clinical translation of research advances, with potential for great medical impact, e.g. through improvements in ciliopathy disease diagnosis, management, family counselling and by enhancing the potential for future genetically tailored approaches to disease therapeutics.

In Silico Ventilation Within the Dose-Volume is Predictive of Lung Function Post-radiation Therapy in Patients with Lung Cancer

Lung cancer is a leading cause of death worldwide. Radiation therapy (RT) is one method to treat this disease. A common side effect of RT for lung cancer is radiation-induced lung damage (RILD) which leads to loss of lung function. RILD often compounds pre-existing smoking-related regional lung function impairment. It is difficult to predict patient outcomes due to large variability in individual response to RT. In this study, the capability of image-based modelling of regional ventilation in lung cancer patients to predict lung function post-RT was investigated. Twenty-five patient-based models were created using CT images to define the airway geometry, size and location of tumour, and distribution of emphysema. Simulated ventilation within the 20 Gy isodose volume showed a statistically significant negative correlation with the change in forced expiratory volume in 1 s 12-months post-RT (p = 0.001, R = - 0.61). Patients with higher simulated ventilation within the 20 Gy isodose volume had a greater loss in lung function post-RT and vice versa. This relationship was only evident with the combined impact of tumour and emphysema, with the location of the emphysema relative to the dose-volume being important. Our results suggest that model-based ventilation measures can be used in the prediction of patient lung function post-RT.

Herbal Medication to Enhance or Modulate Viral Infections

Viral infections and their emergence continue to pose a threat to human lives. Up to the present, there are limited numbers of vaccines that effectively work and few antivirals licensed for use in clinical practice. Added to this is the increase in antiviral resistance, meaning that drugs that do work are at risk of reduced efficacy. The recent global pandemic of coronavirus 2019 has provided evidence for the risk of a preventative vaccination and effective treatment of viruses' subsequent consequences. The aim of this article is to review traditional and herbal treatments for infections, specifically addressing gastrointestinal and respiratory viral infections.

A systematic review and meta-analysis of the effectiveness of virtual reality as an exercise intervention for individuals with a respiratory condition

BACKGROUND

Respiratory diseases impose an immense health burden worldwide and affect millions of people on a global scale. Reduction of exercise tolerance poses a huge health issue affecting patients with a respiratory condition, which is caused by skeletal muscle dysfunction and weakness and by lung function impairment. Virtual reality systems are emerging technologies that have drawn scientists' attention to its potential benefit for rehabilitation.

METHODS

A systematic review and meta-analysis following the PRISMA guidelines was performed to explore the effectiveness of virtual reality gaming and exergaming-based interventions on individuals with respiratory conditions.

RESULTS

Differences between the virtual reality intervention and traditional exercise rehabilitation revealed weak to insignificant effect size for mean heart rate (standardized mean difference, SMD = 0.17; p = 0.002), peak heart rate (SMD = 0.36; p = 0.27), dyspnea (SMD = 0.32; p = 0.13), and oxygen saturation SpO2 (SMD = 0.26; p = 0.096). In addition, other measures were collected, however, to the heterogeneity of reporting, could not be included in the meta-analysis. These included adherence, enjoyment, and drop-out rates.

CONCLUSIONS

The use of VRS as an intervention can provide options for rehabilitation, given their moderate effect for dyspnea and equivalent to weak effect for mean and maximum peak HR and SpO2. However, the use of virtual reality systems, as an intervention, needs further study since the literature lacks standardized methods to accurately analyze the effects of virtual reality for individuals with respiratory conditions, especially for duration, virtual reality system type, adherence, adverse effects, feasibility, enjoyment, and quality of life.

[Masterplan 2025 of the Austrian Society of Pneumology (ASP)-the expected burden and management of respiratory diseases in Austria]

Scientific Members of the Austrian Society of Pneumology describe the expected development in respiratory health and provide guidance towards patient-oriented and cost-efficient respiratory care in Austria.Methods: In November 2017, respiratory care providers (physicians, nurses, physiotherapists) together with patient's advocacy groups and experts in health development, collaborated in workshops on: respiratory health and the environment, bronchial asthma and allergy, COPD, pediatric respiratory disease, respiratory infections, sleep disorders, interventional pneumology, thoracic oncology and orphan diseases.Results: Respiratory disease is extremely prevalent and driven by ill-health behavior, i.e. cigarette smoking, over-eating and physical inactivity. For the majority of respiratory diseases increased prevalence, but decreased hospitalizations are expected.The following measures should be implemented to deal with future challenges:1. Screening and case-finding should be implemented for lung cancer and COPD.2. E-health solutions (telemedicine, personal apps) should be used to facilitate patient management.3. Regional differences in respiratory care should be reduced through E‑health and harmonization of health insurance benefits across Austria.4. Patient education and awareness, to reduce respiratory health illiteracy should be increased, which is essential for sleep disorders but relevant also for other respiratory diseases.5. Respiratory care should be inter-professional, provided via disease-specific boards beyond lung cancer (for ILDs, sleep, allergy)6. Programs for outpatient's pulmonary rehabilitation can have a major impact on respiratory health.7. Increased understanding of molecular pathways will drive personalized medicine, targeted therapy (for asthma, lung cancer) and subsequently health care costs.

Detection-based prioritisation: Framework of multi-laboratory characteristics for asymptomatic COVID-19 carriers based on integrated Entropy-TOPSIS methods

CONTEXT AND BACKGROUND

Corona virus (COVID) has rapidly gained a foothold and caused a global pandemic. Particularists try their best to tackle this global crisis. New challenges outlined from various medical perspectives may require a novel design solution. Asymptomatic COVID-19 carriers show different health conditions and no symptoms; hence, a differentiation process is required to avert the risk of chronic virus carriers.

OBJECTIVES

Laboratory criteria and patient dataset are compulsory in constructing a new framework. Prioritisation is a popular topic and a complex issue for patients with COVID-19, especially for asymptomatic carriers due to multi-laboratory criteria, criterion importance and trade-off amongst these criteria. This study presents new integrated decision-making framework that handles the prioritisation of patients with COVID-19 and can detect the health conditions of asymptomatic carriers.

METHODS

The methodology includes four phases. Firstly, eight important laboratory criteria are chosen using two feature selection approaches. Real and simulation datasets from various medical perspectives are integrated to produce a new dataset involving 56 patients with different health conditions and can be used to check asymptomatic cases that can be detected within the prioritisation configuration. The first phase aims to develop a new decision matrix depending on the intersection between 'multi-laboratory criteria' and 'COVID-19 patient list'. In the second phase, entropy is utilised to set the objective weight, and TOPSIS is adapted to prioritise patients in the third phase. Finally, objective validation is performed.

RESULTS

The patients are prioritised based on the selected criteria in descending order of health situation starting from the worst to the best. The proposed framework can discriminate among mild, serious and critical conditions and put patients in a queue while considering asymptomatic carriers. Validation findings revealed that the patients are classified into four equal groups and showed significant differences in their scores, indicating the validity of ranking.

CONCLUSIONS

This study implies and discusses the numerous benefits of the suggested framework in detecting/recognising the health condition of patients prior to discharge, supporting the hospitalisation characteristics, managing patient care and optimising clinical prediction rule.

Unraveling response mechanism of photosynthetic metabolism and respiratory metabolism to uranium-exposure in Vicia faba

As a natural radionuclide, uranium (U) has obvious phytotoxicity, the purpose of this study is to unravel the response mechanism of U on photosynthetic and respiratory metabolism in plants. Therefore, 14-day-old Vicia faba seedlings were exposed to 0-25 μM U during 72 h. U effects on growth parameters, physiological parameters of plants, and potential phytotoxicity mechanism were investigated by physiological analysis, and metabolome and transcriptome data. U significantly inhibited photosynthesis and respiration of plants. In metabolome analysis, 53 metabolites related to carbohydrate metabolism were identified (13 up-regulated, 12 down-regulated). In transcriptome analysis, U significantly inhibited the expression of photoreactive electron transport chain (up: 0; down: 31), Calvin cycle (up: 0; down: 12) and photorespiration pathway genes (up: 0; down: 8). U significantly inhibited the expression of cellular energy metabolic pathways genes (e.g., glycolysis, TCA cycle, and oxidative phosphorylation pathways) (up 8, down 18). We concluded that U inhibited the expression of genes involved in the photosynthetic metabolic pathway, which caused the decrease of photosynthetic rate. Meanwhile, U inhibited the expression of the electron transport chain genes in the mitochondrial oxidative phosphorylation pathway, which leads to the abnormal energy supply of cells and the inhibition of root respiration rate.

Aerodigestive Disease in Dogs

Aerodigestive disorders (AeroDs) in people encompass a wide range of clinical syndromes, reflecting the complex relationship between the respiratory and digestive tracts. In veterinary medicine, aspiration is used interchangeably with aspiration pneumonia. Although aspiration pneumonia is a common disorder in dogs, it does not reflect the breadth of AeroDs. Unfortunately, AeroDs rarely are investigated in veterinary medicine because of lack of clinical recognition, limitations in available diagnostics, and the fact that AeroDs may be caused by occult digestive disease. Recognizing patients with AerodD represents an area of significant clinical importance that may provide additional areas of clinical intervention.

Deep learning for predicting the occurrence of cardiopulmonary diseases in Nanjing, China

The efficiency of disease prevention and medical care service necessitated the prediction of incidence. However, predictive accuracy and power were largely impeded in a complex system including multiple environmental stressors and health outcome of which the occurrence might be episodic and irregular in time. In this study, we established four different deep learning (DL) models to capture inherent long-term dependencies in sequences and potential complex relationships among constituents by initiating with the original input into a representation at a higher abstract level. We collected 504,555 and 786,324 hospital outpatient visits of grouped categories of respiratory (RESD) and circulatory system disease (CCD), respectively, in Nanjing from 2013 through 2018. The matched observations in time-series that might pose risk to cardiopulmonary health involved conventional air pollutants concentrations and metrological conditions. The results showed that a well-trained network architecture built upon long short-term memory block and a working day enhancer achieved optimal performance by three quantitative statistics, i.e., 0.879 and 0.902 of Nash-Sutcliffe efficiency, 0.921% and 0.667% of percent bias, and 0.347 and 0.312 of root mean square error-standard deviation ratio for RESD and CCD hospital visits, respectively. We observed the non-linear association of nitrogen dioxide and ambient air temperature with CCD hospital visits. Furthermore, these two environmental stressors were identified as the most sensitive predictive variables, and exerted synergetic effect for two health outcomes, particular in winter season. Our study indicated that high-quality surveillance data of atmospheric environments could provide novel opportunity for anticipating temporal trend of cardiopulmonary health outcomes based on DL model.

A combined cohort analysis of prenatal exposure to phthalate mixtures and childhood asthma

BACKGROUND

Previous studies of prenatal phthalate exposure and childhood asthma are inconsistent. These studies typically model phthalates as individual, rather than co-occurring, exposures. We investigated whether prenatal phthalates are associated with childhood wheeze and asthma using a mixtures approach.

METHODS

We studied dyads from two prenatal cohorts in the ECHO-PATHWAYS consortium: CANDLE, recruited 2006-2011 and TIDES, recruited 2011-2013. Parents reported child respiratory outcomes at age 4-6 years: ever asthma, current wheeze (symptoms in past 12 months) and current asthma (two affirmative responses from ever asthma, recent asthma-specific medication use, and/or current wheeze). We quantified 11 phthalate metabolites in third trimester urine and estimated associations with child respiratory outcomes using weighted quantile sum (WQS) logistic regression, using separate models to estimate protective and adverse associations, adjusting for covariates. We examined effect modification by child sex and maternal asthma.

RESULTS

Of 1481 women, most identified as White (46.6%) or Black (44.6%); 17% reported an asthma history. Prevalence of ever asthma, current wheeze and current asthma in children was 12.3%, 15.8% and 12.3%, respectively. Overall, there was no adverse association with respiratory outcomes. In sex-stratified analyses, boys' phthalate index was adversely associated with all outcomes (e.g., boys' ever asthma: adjusted odds ratio per one quintile increase in WQS phthalate index (AOR): 1.42; 95% confidence interval (CI): 1.08, 1.85, with mono-ethyl phthalate (MEP) weighted highest). Adverse associations were also observed in dyads without maternal asthma history, driven by MEP and mono-butyl phthalate (MBP), but not in those with maternal asthma history. We observed protective associations between the phthalate index and respiratory outcomes in analysis of all participants (e.g., ever asthma: AOR; 95% CI: 0.81; 0.68, 0.96), with di(2-ethylhexyl)phthalate (DEHP) metabolites weighted highest.

CONCLUSIONS

Results suggest effect modification by child sex and maternal asthma in associations between prenatal phthalate mixtures and child asthma and wheeze.

Ampakines stimulate phrenic motor output after cervical spinal cord injury

Activation of α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptors increases phrenic motor output. Ampakines are a class of drugs that are positive allosteric modulators of AMPA receptors. We hypothesized that 1) ampakines can stimulate phrenic activity after incomplete cervical spinal cord injury (SCI), and 2) pairing ampakines with brief hypoxia could enable sustained facilitation of phrenic bursting. Phrenic activity was recorded ipsilateral (IL) and contralateral (CL) to C2 spinal cord hemisection (C2Hx) in anesthetized adult rats. Two weeks after C2Hx, ampakine CX717 (15 mg/kg, i.v.) increased IL (61 ± 46% baseline, BL) and CL burst amplitude (47 ± 26%BL) in 8 of 8 rats. After 90 min, IL and CL bursting remained above baseline (BL) in 7 of 8 rats. Pairing ampakine with a single bout of acute hypoxia (5-min, arterial partial pressure of O₂ ~ 50 mmHg) had a variable impact on phrenic bursting, with some rats showing a large facilitation that exceeded the response of the ampakine alone group. At 8 weeks post-C2Hx, 7 of 8 rats increased IL (115 ± 117%BL) and CL burst amplitude (45 ± 27%BL) after ampakine. The IL burst amplitude remained above BL for 90-min in 7 of 8 rats; CL bursting remained elevated in 6 of 8 rats. The sustained impact of ampakine at 8 weeks was not enhanced by hypoxia exposure. Intravenous vehicle (10% 2-Hydroxypropyl-β-cyclodextrin) did not increase phrenic bursting at either time point. We conclude that ampakines effectively stimulate neural drive to the diaphragm after cervical SCI. Pairing ampakines with a single hypoxic exposure did not consistently enhance phrenic motor facilitation.

An integrated multidisciplinary model of COVID-19 recovery care

Background

In January 2020, the WHO declared the SARS-CoV-2 outbreak a public health emergency; by March 11, a pandemic was declared. To date in Ireland, over 3300 patients have been admitted to acute hospitals as a result of infection with COVID-19.

Aims

This article aims to describe the establishment of a COVID Recovery Service, a multidisciplinary service for comprehensive follow-up of patients with a hospital diagnosis of COVID-19 pneumonia.

Methods

A hybrid model of virtual and in-person clinics was established, supported by a multidisciplinary team consisting of respiratory, critical care, infectious diseases, psychiatry, and psychology services. This model identifies patients who need enhanced follow-up following COVID-19 pneumonia and aims to support patients with complications of COVID-19 and those who require integrated community care.

Results

We describe a post-COVID-19 service structure together with detailed protocols for multidisciplinary follow-up. One hundred seventy-four patients were discharged from Beaumont Hospital after COVID-19 pneumonia. Sixty-seven percent were male with a median age (IQR) of 66.5 (51–97). Twenty-two percent were admitted to the ICU for mechanical ventilation, 11% had non-invasive ventilation or high flow oxygen, and 67% did not have specialist respiratory support. Early data suggests that 48% of these patients will require medium to long-term specialist follow-up.

Conclusions

We demonstrate the implementation of an integrated multidisciplinary approach to patients with COVID-19, identifying those with increased physical and mental healthcare needs. Our initial experience suggests that significant physical, psychological, and cognitive impairments may persist despite clinical resolution of the infection.

The association between regular cocaine use, with and without tobacco co-use, and adverse cardiovascular and respiratory outcomes

BACKGROUND

Understanding the potential impact of cocaine use on health is increasingly important as cocaine use rises in the U.S.

OBJECTIVES

This study evaluated the associations of regular cocaine use, with and without tobacco co-use, with cardiovascular and respiratory outcomes.

METHODS

Analysis of a limited dataset obtained through IBM Watson Health Explorys, a platform integrating electronic health record data. Matched controls were defined for: 1) cocaine-using patients (n = 8244; 44 % female); and subgroups of cocaine-using patients: 2) with an encounter diagnosis for tobacco use disorder (TUD; n = 4706); and 3) without a TUD diagnosis (non-TUD; n = 3538). Patients had at least one documented medical evaluation in the MetroHealth System (Cleveland, Ohio). Cocaine-using patients had an encounter diagnosis of cocaine abuse/dependence and/or ≥2 cocaine-positive drug screens. Control patients, with no documented cocaine-use, were matched to the cocaine-using patients on demographics, residential zip code median income, body mass index, and, for the total sample, TUD-status. Outcomes were encounter diagnosis (yes/no) of cerebrovascular accident, heart arrhythmia, myocardial infarction, subarachnoid hemorrhage, asthma, chronic obstructive pulmonary disease (COPD), pneumonia, and all-cause mortality.

RESULTS

TUD-patients had the greatest prevalence of cardiovascular and respiratory disease, regardless of cocaine-use indication. In the total sample, TUD, and non-TUD subgroups, regular cocaine use was significantly associated with greater risk for cerebrovascular accident, arrhythmia, myocardial infarction, asthma, COPD, pneumonia and mortality.

CONCLUSIONS

Cocaine use is associated with significantly greater risk of adverse cardiovascular and respiratory diagnoses and all-cause mortality.

Quantification of bis(2-ethylhexyl) phthalate released by medical devices during respiratory assistance and estimation of patient exposure

Bis(2-ethylhexyl) phthalate (DEHP) migration from polyvinyl chloride (PVC) has been studied with infusion, transfusion and extracorporeal oxygenation devices, but no study has been conducted to estimate its migration via respiratory medical devices (MDs). This work aims to develop an ex vivo model to quantify DEHP released doses by these MDs, which will then be used to estimate newborns DEHP exposure from respiratory assistance MDs. We followed the Frensh National Research and Safety Institute (INRS) recommendations for the validation of a collecting and analysing method of DEHP in air, which will be used to quantify DEHP in air passing through PVC respiratory assistance MDs. The developed method met all the validation criteria for DEHP determination in air. DEHP in air passing through MDs on the sixth day reached a cumulative quantity of 122.86 μg when using a flow rate of 4 L min^-1 of non-humidified air while it was of 49.22 μg; 58.12 μg and 29.61 μg with flow rates of 2 L min^-1 of humidified air, 2 L min^-1 of dry air and 4 L min^-1 of humidified air, respectively. Model application to two patients undergoing two different respiratory procedure demonstrated that noninvasive ventilation patient received higher dose of inhaled DEHP, confirmed by DEHP metabolites quantification in urine. Although the protective effect of air humidifiers on DEHP exposure was demonstrated, the effect of flow rate is difficult to be established. This developed method should be tested to verify its capacity to collect and quantify other plasticizers used in PVC MDs.

ENDS use among college students: Salivary biomarkers and persistent cough

Though e-cigarette aerosol has been associated with altered lung cell function, few studies have examined the effects of use on immune response and respiratory symptoms. The purpose of this study was to examine if recent persistent cough or cytokine levels are related to Electronic Nicotine Delivery Systems (ENDS) use in college students. In April 2019, 61 undergraduate students at the University of Kentucky completed surveys and provided a salivary sample to evaluate cytokine levels (Interleukin (IL-) 2, 4, 6, 8, 10, 12, 13 and TNFα, INFγ), using quota sampling to obtain comparable numbers of ENDS users and non-ENDS users. Data analysis included chi-square tests and multivariable logistic and linear regression. All ENDS users reported JUUL as their primary product. ENDS users were more likely to be younger, use cigarettes and marijuana, and report a persistent cough. Controlling for cigarette and marijuana use, there was a trend toward greater likelihood of persistent cough among ENDS users. Compared with nonusers, salivary IL-2 and INFγ were elevated and IL-4 was decreased, controlling for cigarette and marijuana use. There was a trend toward lower IL-12p70 values among ENDS users with these covariates. Findings reveal dysregulation of salivary immune profiles toward a T_H1 phenotype in emerging adult ENDS users and short-term immune function may be dysregulated in young adult e-cigarette users.

Fistulas between the Esophagus and Adjacent Vital Organs in Esophageal Cancer

Esophageal fistulas may occur in an advanced stage or as a potentially life-threatening complication of treatment. They can be divided into esophageal-respiratory and esophageal-aorta fistulas. The diagnosis is confirmed with fluoroscopy using dilute barium oral contrast, followed by thin-section computed tomography, which defines the precise location and extent of the fistula. Flexible esophagoscopy and bronchoscopy are required for confirmation and anatomic assessment of the suspected fistula and provide additional information for treatment planning. Contamination is traditionally controlled by surgical exclusion, along with a jejunal feeding tube. Currently, fully covered self-expanding metal stents are the primary treatment option.

Comparison of acute respiratory epithelial toxicity for 4-Methylimidazole and naphthalene administered by oral gavage in B6C3F1 mice

4-Methylimidazole (4MEI) is a contaminant in food and consumer products. Pulmonary toxicity and carcinogenicity following chronic dietary exposures to 4MEI is a regulatory concern based on previous rodent studies. This study examined acute pulmonary toxicity in B6C3F1 mice from 6 h to 5 days after oral gavage with a single dose of 150 mg/kg 4MEI, a double dose delivered 6 h apart, or vehicle controls. Oral gavage of 150 mg/kg naphthalene, a prototypical Club cell toxicant, was used as a positive control. Intrapulmonary conducting airway cytotoxicity was assessed in fixed-pressure inflated lungs using qualitative histopathology scoring, quantitative morphometric measurement of vacuolated and exfoliating epithelial cells, and immunohistochemistry. 4MEI treatment did not change markers of cytotoxicity including the mass of vacuolated epithelium, the thickness of the epithelium, or the distributions of epithelial proteins: secretoglobin 1A1, proliferating cell nuclear antigen, calcitonin gene-related peptide, and myeloperoxidase. 4MEI and vehicle controls caused slight cytotoxicity with rare vacuolization of the epithelium relative to the severe bronchiolar epithelial cell toxicity found in the naphthalene exposed mice at terminal bronchioles, intrapulmonary airways, or airway bifurcations. In summary, 4MEI caused minimal airway epithelial toxicity without characteristic Club Cell toxicity when compared to naphthalene, a canonical Club Cell toxicant.

Respiratory, birth and health economic measures for use with Indigenous Australian infants in a research trial: a modified Delphi with an Indigenous panel

Background

There is significant disparity between the respiratory health of Indigenous and non-Indigenous Australian infants. There is no culturally accepted measure to collect respiratory health outcomes in Indigenous infants. The aim of this study was to gain end user and expert consensus on the most relevant and acceptable respiratory and birth measures for Indigenous infants at birth, between birth and 6 months, and at 6 months of age follow-up for use in a research trial.

Methods

A three round modified Delphi process was conducted from February 2018 to April 2019. Eight Indigenous panel members, and 18 Indigenous women participated. Items reached consensus if 7/8 (≥80%) panel members indicated the item was ‘very essential’. Qualitative responses by Indigenous women and the panel were used to modify the 6 months of age surveys.

Results

In total, 15 items for birth, 48 items from 1 to 6 months, and five potential questionnaires for use at 6 months of age were considered. Of those, 15 measures for birth were accepted, i.e., gestational age, birth weight, Neonatal Intensive Care Unit (NICU) admissions, length, head circumference, sex, Apgar score, substance use, cord blood gas values, labour, birth type, health of the mother, number people living in the home, education of mother and place of residence. Seventeen measures from 1-to 6 months of age were accepted, i.e., acute respiratory symptoms (7), general health items (2), health care utilisation (6), exposure to tobacco smoke (1), and breastfeeding status (1). Three questionnaires for use at 6 months of age were accepted, i.e., a shortened 33-item respiratory questionnaire, a clinical history survey and a developmental questionnaire.

Conclusions

In a modified Delphi process with an Indigenous panel, measures and items were proposed for use to assess respiratory, birth and health economic outcomes in Indigenous Australian infants between birth and 6 months of age. This initial step can be used to develop a set of relevant and acceptable measures to report respiratory illness and birth outcomes in community based Indigenous infants.

COVID-19 and anosmia in Tehran, Iran

Patients with acute olfactory disorders typically present to the otolaryngologist with both acute hyposmia and less often with anosmia. With the onset of COVID-19 we have noticed an increase in the number of patients who have presented with new onset of complete smell loss to the senior author's practice in Tehran, Iran. This anosmia and the frequency with which patients present is highly unusual. Coronaviruses have been known to cause common cold symptoms. COVID-19 infections have been described as causing more severe respiratory infections and the symptoms reported by authors from Wuhan, China have not specifically included anosmia. We describe patients who have presented during a two-week period of the COVID-19 pandemic with complete loss of sense of smell. Most had either no symptoms or mild respiratory symptoms. Many had a normal otolaryngologic exam. A relationship between COVID-19 and anosmia should be considered during the pandemic. We hypothesize that the mechanism of injury is similar to that of other coronavirus infections that cause central and peripheral neurologic deficits.

A lung for all: Novel mechanical ventilator for emergency and low-resource settings

Aims

To create a low-cost ventilator that could be constructed with readily-available hospital equipment for use in emergency or low-resource settings.

Main methods

The novel ventilator consists of an inspiratory limb composed of an elastic flow-inflating bag encased within a non-compliant outer sheath and an expiratory limb composed of a series of two, one-way bidirectional splitter valves derived from a self-inflating bag system. An Arduino Uno microcontroller controls a solenoid valve that can be programmed to open and close to produce a set respiratory rate and inspiratory time. Using an ASL 5000 Lung Simulator, we obtained flow, pressure, and volume waveforms at different lung compliances.

Key findings

At a static lung compliance of 50 mL/cm H₂O and an airway resistance of 6 cm H₂O/L/s, ventilated at a PIP and PEEP of 16 and 5 cm H₂O, respectively, tidal volumes of approximately 540 mL were achieved. At a static lung compliance of 20 mL/cm H₂O and an airway resistance of 6 cm H₂O/L/s, ventilated at a PIP and PEEP of 38 and 15 cm H₂O, respectively, tidal volumes of approximately 495 mL were achieved.

Significance

This novel ventilator is able to safely and reliably ventilate patients with a range of pulmonary disease in a simulated setting. Opportunities exist to utilize our ventilator in emergency situations and low-resource settings.

Isolated and Combined Respiratory Training for Muscle Tension Dysphonia: Preliminary Findings

PURPOSE

The purpose of this study was to determine the feasibility of altering speech breathing patterns and dysphonia severity through training increased levels of lung volume use during speech. It was hypothesized that respiratory-based training would increase lung volume levels during speech as well as improve acoustic voice measures, and that the addition of laryngeal-based treatment would further improve voice acoustics by treatment completion.

METHOD

A multiple baseline, single subject design was replicated over six participants with primary muscle tension dysphonia as a preliminary investigation of novel respiratory treatment methods. Following four baseline probes (1-4), two phases of treatment were implemented over 6 weeks. Respiratory lung volume-based training (RLVT) and subsequent performance was probed at sessions 5 to 7 and laryngeal-based training was added to the RLVT and probed at sessions 8 to 10. Visual biofeedback was used during RLVT to assist the motor learning process. Respiratory outcome measures of lung volume initiation, termination and excursion were objectively measured using respiratory plethysmography (InductoTrace), and cepstral and spectral-based acoustic measures were also determined at each time point.

RESULTS

All participants showed improvement in one or more respiratory measures as well as reduced acoustic dysphonia severity following phase 1 of RLVT alone. Two participants achieved further marked improvement in acoustic voice measures after laryngeal-based training was added in phase 2 of treatment, but this was generally also accompanied by further improvement or stabilization of respiratory measures.

CONCLUSION

Results from this preliminary study support the feasibility of RLVT for improving speech breathing behavior, and suggest that RLVT alone can improve objectively measured dysphonia severity.

Treatment patterns, healthcare resource utilization, and costs among patients with idiopathic pulmonary fibrosis treated with antifibrotic medications in US-based commercial and Medicare Supplemental claims databases: a retrospective cohort study

BACKGROUND

Pirfenidone and nintedanib are antifibrotic therapies which slow disease progression in idiopathic pulmonary fibrosis (IPF), an irreversible, progressive lung disease with poor prognosis. We compared adherence, persistence, and healthcare costs between patients initiating one of the two therapies.

METHODS

We used the IBM Watson Health Commercial and Medicare Supplemental claims databases to select patients with IPF with ≥1 pharmacy claim for pirfenidone or nintedanib between 10/1/2014 and 6/30/2018. Adherence (proportion of days covered ≥0.80) and persistence (time to a gap of ≥60 days without medication or switch to the other antifibrotic medication) based on the days' supply and service date fields on claims were measured over a variable-length follow-up period. Healthcare costs, all-cause and respiratory-related, were measured over the persistent period and a fixed 12-month follow-up period. Inverse probability of treatment weights were applied to models comparing adherence, persistence, and costs between the two cohorts.

RESULTS

Overall, 799 pirfenidone patients and 656 nintedanib patients were identified. Similar proportions of patients were adherent in both cohorts (pirfenidone = 49% vs. nintedanib = 51%) and there was no significant difference in the odds of being adherent after weighting (odds ratio = 1.1, p = 0.513). The proportions of patients who discontinued/switched were also similar (pirfenidone = 41% vs. nintedanib 43%); however, in a weighted model, the hazards of discontinuation/switching was lower for the pirfenidone cohort (hazard ratio = 0.8, p = 0.032). While patients were persistent on therapy, weighted all-cause healthcare costs were comparable (pirfenidone = $11,272 vs. nintedanib = $11,987 per-patient per-month; p = 0.115), but weighted respiratory-related costs were significantly lower for the pirfenidone cohort ($9015 vs. $10,167 per-patient per-month, p < 0.001). Weighted annual total all-cause and respiratory-related healthcare costs were comparable between cohorts over the fixed 12-month follow-up period, but the pirfenidone cohort had significantly lower weighted annual mean antifibrotic drug costs than the nintedanib cohort ($68,850 vs. $77,033, p = 0.007).

CONCLUSIONS

Pirfenidone use was associated with longer time to discontinuation/switch, lower antifibrotic drug costs, and lower respiratory-related total costs compared to nintedanib use.

Effects of acute inspiratory loading during treadmill running on cerebral, locomotor and respiratory muscle oxygenation in women soccer players

Respiratory limitation can be a primary mechanism for exercise cessation in female athletes. This study aimed to assess the effects of inspiratory loading (IL) on intercostal muscles (IM), vastus lateralis (VL) and cerebral (Cox) muscles oxygenation in women soccer players during high-intensity dynamic exercise. Ten female soccer players were randomized to perform in order two constant-load tests on a treadmill until the exhaustion time (Tlim) (100 % of maximal oxygen uptake- V˙O₂). They breathed freely or against a fixed inspiratory loading (IL) of 41 cm H₂O (∼30 % of maximal inspiratory pressure). Oxygenated (Δ[OxyHb]), deoxygenated (Δ[DeoxyHb]), total hemoglobin (Δ[tHb]) and tissue saturation index (ΔTSI) were obtained by NIRs. Also, blood lactate [La^-] was obtained. IL significantly reduced Tlim (224 ± 54 vs 78 ± 20; P < 0.05) and increased [La^-], V˙O₂, respiratory cycles and dyspnea when corrected to Tlim (P < 0.05). IL also resulted in decrease of Δ[OxyHb] of Cox and IM during exercise compared with rest condition. In addition, decrease of Δ[OxyHb] was observed on IM during exercise when contrasted with Sham (P < 0.05). Furthermore, significant higher Δ[DeoxyHb] of IM and significant lower Δ[DeoxyHb] of Cox were observed when IL was applied during exercise in contrast with Sham (P < 0.05). These results were accompanied with significant reduction of Δ[tHb] and ΔTSI of IM and VL when IL was applied (P < 0.05). High-intensity exercise with IL decreased respiratory and peripheral muscle oxygenation with negative impact on exercise performance. However, the increase in ventilatory work did not impact cerebral oxygenation in soccer players.

Evaluating changes in ambient ozone and respiratory-related healthcare utilization in the Washington, DC metropolitan area

Ozone pollution is a known respiratory irritant, yet we do not fully understand the magnitude or timing of respiratory effects based on short-term exposure. We investigated the associations between ambient ozone concentrations and respiratory symptoms as measured by healthcare utilization events. We used comprehensive electronic health records to identify respiratory responses to changes in ambient ozone levels. We constructed a dataset from Kaiser Permanente Mid-Atlantic States (KPMAS) that included information on 2013 and 2014 daily utilization rates for a broad range of healthcare utilization - nurse calls/emails, provider visits, emergency department and urgent care visits (ED/UC) and hospital admissions - by census block. We used 8-h average ozone concentrations collected from 48 air monitoring stations in the region via the Air Data database of the USEPA. We estimated the association between changes in ambient ozone (exposure windows of current day, 1-day lag and 3-day moving average) and changes in healthcare utilization using linear regression controlling for census tract-level socioeconomic indicators and temperature. Increases in ozone were associated with increases in three of the four utilization event types. A 10 ppb increase in 1-day ozone was associated with a 2.95% (95% CI: 1.93%, 3.96%) increase in calls/emails, a 1.56% (95% CI: 0.38%, 2.74%) increase in ED/UC visits and a 1.10% (95% CI: 0.48%, 1.73%) increase in provider visits. We did not find associations between ozone and hospital admissions. Proportionally, highest effects were found for nurse calls/emails possibly indicating a high number of mild effects that may be underreported in studies that examine only ED visits or hospital admissions.

Enrichment of the airway microbiome in people living with HIV with potential pathogenic bacteria despite antiretroviral therapy

BACKGROUND

Long-term antiretroviral therapy (ART) enables people living with HIV (PLW-HIV) to be healthier and live longer; though they remain at greater risk of pneumonia and chronic lung disease than the general population. Lung microbial dysbiosis has been shown to contribute to respiratory disease.

METHODS

16S-rRNA gene sequencing on the Miseq-platform and qPCR for typical respiratory pathogens were performed on sputum samples collected from 64 PLW-HIV (median blood CD4 count 676 cells/μL) and 38 HIV-negative participants.

FINDING

Richness and α-diversity as well as the relative-abundance (RA) of the major taxa (RA>1%) were similar between both groups. In unweighted-Unifrac ß-diversity, the samples from PLW-HIV showed greater diversity, in contrast to the HIV negative samples which clustered together. Gut bacterial taxa such as Bilophila and members of Enterobacteriaceae as well as pathogenic respiratory taxa (Staphylococcus, Pseudomonas and Klebsiella) were significantly more frequent in PLW-HIV and almost absent in the HIV-negative group. Carriage of these taxa was correlated with the length of time between HIV diagnosis and initiation of ART (Spearman-rho=0·279, p=0·028).

INTERPRETATION

Although the core airway microbiome was indistinguishable between PLW-HIV on effective ART and HIV-negative participants, PLW-HIV's respiratory microbiome was enriched with potential respiratory pathogens and gut bacteria. The observed differences in PLW-HIV may be due to HIV infection altering the local lung microenvironment to be more permissive to harbour pathogenic bacteria that could contribute to respiratory comorbidities. Prompt start of ART for PLW-HIV may reduce this risk.